You are not going crazy! You may feel as if you’re going crazy at times—or most of the time—but you’re not. Whether you’re experiencing more angry outbursts, down-in-the-dump moods, frazzled thinking, or more severe distress, know that it is not just in your head.
“Many women are shocked by the mood swings, anger, and anxiety that can start in the perimenopause,” says gynecologist Rebecca Dunsmoor-Su, M.D., chief medical officer at Gennev.
Instead of simply ignoring a quirky habit that your partner has, like you used to do, you now blow. And then, after a heated argument about something that, in the grand scheme of life, isn’t important, you feel guilty and wonder what’s wrong with you. Or maybe the nervousness you used to have about public speaking now becomes a full-blown panic attack. “It is due to the way the brain responds to the hormone swings that happen naturally during this time, but that does not make you simply hormonal,” says Dr. Dunsmoor-Su. “The symptoms can be even worse if you are someone who has these at baseline.”
Mental health issues are real and common in perimenopause and menopause, but there’s help. You’re not alone. And, you don’t have to suffer through it alone.
In general, women experience mental health problems at a higher rate than men—1 in 5 women compared to 1 in 8 men. The incidence increases during the menopausal years. One in three women, ages 50 to 64, reported needing mental health care in the past two years, according to the 2022 Kaiser Family Foundation Women’s Health Survey.
It’s completely normal to feel more emotional or have a harder time controlling your emotions during this stage of life. Along with the usual life stresses, women’s relationships are often shifting at this time. Their kids are leaving home. Parents may require more care. “All those things are going to impact a woman’s mental health,” says Dr. Dunsmoor-Su.
And then add in a rollercoaster of hormones. “The brain is exquisitely sensitive to estrogen and progesterone,” says Dr. Dunsmoor-Su. “It's had these hormones in a particular pattern its whole life, and now that pattern is broken. The brain is behaving differently because the pattern is different.” And the pattern keeps changing, resulting in different symptoms as you progress from perimenopause to menopause.
Perimenopause is the two- to 10-year transitional period to menopause when a woman stops menstruating. During perimenopause, though, a woman is still getting her periods, but they may be more erratic. Every month, there is a surge of estrogen in the first half of the cycle and a surge of progesterone in the second half. The ovaries are still producing eggs, but more estrogen is needed to stimulate them. Through the cycle, estrogen levels get higher, progesterone levels increase to match the high estrogen, and then all of the hormones drop. “You get really big spikes of hormones,” says Dr. Dunsmoor-Su. “You get really big troughs of hormones. It's a roller coaster of hormones, and the brain doesn't like roller coasters. The brain likes nice, sedate walks on a path.”
These drastic fluctuations often predispose women to anxiety, anger, and mood swings. Some women also experience depression or worsening of their symptoms if they already had depression before perimenopause. Those symptoms may also be worse for women who’ve previously experienced premenstrual syndrome (PMS) or its more severe counterpart, premenstrual dysphoric disorder (PMDD). The good news is that these mental health issues tend to be temporary symptoms associated with perimenopause. As your hormone levels decline and fewer fluctuations occur, mood swings and anxiety often lessen. However, depression can be more common after menopause.
Menopause is achieved once you’ve gone 12 months without a period. “In post-menopause, there is very low estrogen and basically no progesterone,” says Dr. Dunsmoor-Su. The decline in hormones tends to level out mood swings, ease anxiety, and tame anger, but can be associated with an increase in depression. In addition to the effect of hormones on your mood, other frequent postmenopausal issues such as hot flashes, poor sleep, body changes, and stress can all contribute to depression. Studies associate increased hot flashes with increased depression. Symptoms are often worse for women who’ve had depression at other times in their lives. And 15 to 20 percent of women may be diagnosed with new-onset depression in midlife.
Unlike anxiety and mood swings, which tend to resolve once you’re postmenopausal, depression may stick around. “If you're someone who has had depression your whole life, you may get a temporary exacerbation through the menopausal transition, and then it might get somewhat better,” says Dr. Dunsmoor-Su. “These things wax and wane.”
Despite these general patterns in mental health symptoms during midlife, the experience can differ from one woman to the next. “It's a fluid time,” says Dr. Dunsmoor-Su. “Every woman's journey is different. They’re going to go through the same hormonal changes, but the way their brain behaves is very different because of the different patterns of estrogen and progesterone receptors in the brain.” And because women’s menopause experiences vary, treatments can vary, too.
Immediately! As women, we tend to take care of everyone else first and often put our needs aside. But this strategy isn’t helpful for anyone over time. Think of it this way, what would be the most effective way of saving your loved ones if you were all in a leaky life raft? You’d wear yourself out and wouldn’t save anyone if you’re madly bailing the water. But if you take the time to patch the leak, you’ll save everyone without sacrificing yourself.
“Menopause is already a stressful time on the body, says Dr. Dunsmoor-Su. “It impacts your long-term health, sense of well-being, cardiovascular health, and longevity. It’s important to care for yourself because this is the beginning of the rest of your life. You’ve got a solid 30 to 40 more years to live, and you want to do it in the healthiest way possible. If you don't address your sources of stress, mental health being one of them, it can be harder to live a healthy life.”
Now isn’t the time to try to push through it or let the stigma of mental health issues prevent you from seeking help. If you notice that any of these mental, psychological, or emotional issues are impacting your quality of life, you should talk to your doctor or healthcare provider. Common signs that it’s time to take care of your mental health may include feeling less able to manage day-to-day, negative changes in relationships, problems at work, a lack of desire to participate in activities that you used to enjoy, or others noticing a difference in you.
If any of these apply to you, talk to your primary care doctor, gynecologist, or menopause doctor. Let them know that you’ve noticed these changes in your mental health and want to know what resources are available. You can also ask for a referral to a mental health professional.
Sometimes mental health issues can be severe and require immediate attention. According to a European epidemiological study across the reproductive life cycle of women, suicidal ideation increases during the menopause transition. The study showed a 7-fold increase in suicidal ideation in perimenopause versus other women. If you are experiencing any thoughts about hurting yourself or others, seek help right away.
As menopausal mental health problems differ from one woman to another, so do treatments. The course of action often depends on the severity of symptoms and can range from lifestyle interventions or therapy to hormone therapy or medications.
During perimenopause, low-dose birth control pills may be enough to quell mild to moderate anxiety, depression, and mood swings. “There is some good data that in perimenopause hormone therapy is as effective as SSRIs (the most common antidepressants such as Prozac) for managing depressive and anxiety symptoms,” says Dr. Dunsmoor-Su. For postmenopausal women, a combination of estrogen and antidepressants works better than either alone, according to research.
Therapy is another option that may complement other treatments or work on its own. “Having behavioral techniques that you can use when you're feeling very stressed or anxious can be really helpful during this time,” says Dr. Dunsmoor-Su.
“We have to look at each patient as an individual,” she says. “One patient may need mental health care. One patient may need hormones, and one patient may need both. It's about taking a holistic look at the patient and her symptoms and figuring out how we can help.”
You deserve the best care for your physical and mental health in menopause. Together with LifeStance Health, one of the nation's largest providers of virtual and in-person outpatient mental healthcare, Gennev offers access to menopause-trained OB/GYNs, psychiatrists, psychologists, licensed therapists, and dietitians who provide guidance, prescription support, and lifestyle therapies for your mind and body through this important stage of life.
Learn more about how Gennev patients receive integrated care that addresses both the physical and mental health symptoms associated with menopause.
If your concerns feel too heavy to handle, there is no shame in seeking professional help: Call, text, or chat 988 to reach the National Suicide Prevention Lifeline, and you will be connected to trained counselors that are part of the existing Lifeline network. You can also dial 800-273-8255 or chat via the web at 988lifeline.org/chat/.
The information on the Gennev site is never meant to replace the care of a qualified medical professional. Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev's telemedicine doctors before beginning any new treatment or therapy.